Palliative Care With Tracheostomy or Gastrostomy Tube Use and End-of-Life Quality and Costs Among Patients With Head and Neck Cancer

Abstract

Importance: Patients with head and neck cancer (HNC) have high utilization rates of tracheostomy or gastrostomy tubes (g-tubes) at the end of life, with accompanying high costs. It is unknown whether the timing of palliative care (PC) initiation may attenuate the cost or be associated with better quality of life during the last year and more home deaths.

Objective: To assess the association of palliative care (first exposure) and tracheostomy or g-tube utilization with end-of-life costs among patients with head and neck cancer during the last year of life.

Design, setting, and population: This was a population-based cohort study of adults diagnosed with HNC between January 1, 2007, and December 31, 2022, who died before October 1, 2023, in Ontario, Canada. Health administrative data were deterministically linked and analyzed at the ICES (formerly Institute for Clinical Evaluative Sciences). Data analysis was conducted from January 2024 to June 2025.

Exposures: Timing of PC, categorized as early (12 to 6 months before death), late (<6 months before death), and none (no PC during last year of life), was combined with tracheostomy tube use (binary) to form a 6-level categorical variable. This procedure was repeated for g-tube.

Main outcomes: Mean monthly health care costs in last 6 months of life were estimated using a patient-level case-costing algorithm using 2023 CAD$ (CAD$ 1.00 = US$ 0.74) and evaluated by negative binomial regression.

Results: The analysis included 11 135 adults who received a diagnosis of HNC from 2007 to 2022 and died before October 1, 2023. They had a mean (SD) age of 68.4 (12.1) years at diagnosis and 8245 were male (74.0%). Nearly 90% received PC: 5866 (52.6%), late PC; 4093 (36.8%), early PC; and 1176 (10.6%) did not receive PC. Regarding tracheostomy/g-tube use in the last year of life, 1293 (11.6%) used a tracheostomy and 1235 (11.1%), a g-tube. Compared to those who did not receive PC nor use a tracheostomy tube, the cost increase on using a tracheostomy tube (rate ratio [RR] 2.93; 95% CI, 2.32-3.71) was higher than using it with early PC (RR, 2.88; 95% CI, 2.63-3.15) but lower than using it with late PC (RR 4.37; 95% CI, 4.00-4.77); results were similar for g-tube use. A large proportion of the cohort had an emergency department visit (9109 [81%]) or a non-PC hospital admission (5419 [48.7%]) in last 6 months of life, with both proportions being the lowest among nonrecipients of PC. Early PC was associated with a 46.8% lower likelihood (odd ratio, 0.53; 95% CI, 0.45-0.63) of experiencing a home death than no PC.

Conclusions and relevance: This cohort study found that receiving a tracheostomy/g-tube in last year of life has pronounced economic implications to the health care system. Early initiation of PC may attenuate this high cost but may not reduce the use of aggressive hospital-based care at the end of life or facilitate home deaths. Team-based early provision of PC for this patient population is required.